Jayme Cotter, MS, RN,
When chemotherapy involves tricky infusion timing, patients are routinely admitted to hospitals to receive their treatments. But what would happen if these drugs could be administered successfully on an outpatient basis?
In a study of the issue, staff members at Froedtert & Medical College of Wisconsin, in Milwaukee, demonstrated that moving the administration of the anti-metabolite cytarabine from the inpatient to the outpatient setting improved patient quality of life and opened up more hospital beds for people who were very ill. In addition, the model is expected to save a lot of money, the study’s authors found.
Lead author Jayme Cotter, MS, RN, AOCNS, ACNS-BC, reported the findings April 29 during the 2016 ONS Congress in San Antonio, Texas.
Cotter noted that high-dose cytarabine (also known as HiDAC), when given as consolidation therapy in acute myeloid leukemia, is typically administered in two two-hour infusions 12 hours apart on days 1, 3 and 5 of a cycle, with lab values carefully monitored during the process. In the past, that has necessitated a six-day hospital admission.
Giving the same treatment in outpatient infusion centers has been considered impossible because many facilities were open only during regular business hours, a window of time that was too short.
Froedtert was able to address this problem by taking advantage of the expanded hours of its high-volume outpatient infusion center, which is now open from 6:30 or 7 a.m. through 8 p.m., Cotter said. In concert with this, the hospital dropped the time between infusions to 11 hours rather than 12; on a single day, the two infusions are treated as separate appointments, with patients free to leave in between. Blood draws for lab work have also been modified under the new plan, with no draws on days one through five; blood is drawn on the morning of the first treatment and not again until the second treatment on the third day. The modified plan makes it possible for patients to visit infusions centers on days 1, 3 and 5 of their cycles, with no appointments on days 2 or 4.
The plan was devised by Froedtert nurses, doctors and pharmacists and, to make it work, they came up with additional interventions related to scheduling, Cotter said. Under the plan, physicians are asked to warn each patient and the medical team seven days before they give cytarabine, allowing time to accomplish pre-chemotherapy education and preschedule follow-up care, such as clinic visits for lab work evaluations, and possibly transfusions.
Nurses receive a checklist of tasks and an explanation of how to conduct neurologic assessments for cerebellar toxicities. Patients, considered partners in their own care, get a calendar explaining their responsibilities before, during and after treatment, including which medicines, such as oral anti-emetics, to take, and when. In addition to standardized written information, every patient has an educational meeting with both a nurse and a pharmacist.
The shift to outpatient treatment has not only “enhanced the patient experience,” but had “significant financial implications,” Cotter said.
The cost difference between the inpatient and outpatient administration of cytarabine is $15,000 per patient, with inpatient infusion costing $25,600 and outpatient infusion priced at $10,700, she said. And while cytarabine itself is extremely inexpensive on either an inpatient or outpatient basis, the same change in treatment settings when administering a drug like rituximab (Rituxan) would represent a large cost difference. Specifically, Cotter said, a 500 mg vial of rituximab would cost $4,000 on an inpatient basis but only $1,500 for an outpatient.
The team plans to find out more about the financial implications of the change by replicating the experiment using drugs other than cytarabine. First, Cotter said, will be the R-EPOCH chemotherapy regimen.
When it comes to administering cytarabine, she said, Froedtert already considers the three-day outpatient plan its standard of care.
“As inpatient areas are pressed for bed availability and more care is transitioned to outpatient, the idea of requiring regimens to be given in one care setting needs re-evaluation,” she said.
Cotter J, Waggoner M, Lahr S, et al. Moving out: transitioning an inpatient chemotherapy regimen to the outpatient setting. Presented at: The 41st Annual Congress of the Oncology Nursing Society; April 27-May 1, 2016; San Antonio, Texas. Podium Abstract.
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